Application for Affiliated Clinical Faculty Status

Select:

I. IDENTIFYING INFORMATION

Name:

Primary Office Address:

Telephone:

Primary Email Address:

II. ACADEMIC & LICENSURE INFORMATION

Name and address of College/University Or Technical School

Did you Graduate?

Yes

Degree Awarded

Major/Discipline

Certifications/Licenses and Dates Obtained:

III. PRACTICE INFORMATION

Type, Location, and Date(s) of Practice:

IV. MISCONDUCT

Has your ability to practice ever been suspended, restricted, terminated, curtailed, or not renewed at any time?

If yes, please explain:

V. AGREEMENT TO ADHERE TO ST. JOHN'S UNIVERSITY RULES AND POLICIES

By signing below, you understand and affirm that St. John's University may terminate your clinical affiliation if St. John's University determines that your clinical affiliation is no longer consistent with the interests of St. John's University.

Signature

Sign above

Date: